Indian Guidelines for Indications and Timing of Intervention for Common Congenital Heart Diseases: Revised and Updated Consensus Statement of the Working Group on Management of Congenital Heart Diseases. Abridged Secondary Publication

ustification: A number of guidelines are available for management of congenital heart diseases from infancy to adult life. However,these guidelines are for patients living in high income countries. Separate guidelines, applicable to Indian children, are required whenrecommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and mayhave co-existing morbidities and malnutrition. Process: Guidelines emerged following expert deliberations at the National ConsensusMeeting on Management of Congenital Heart Diseases in India, held on 10th and 11th of August 2018 at the All India Institute of MedicalSciences, New Delhi. The meeting was supported by Children’s HeartLink, a non-governmental organization based in Minnesota, USA.Objectives: To frame evidence based guidelines for (i) indications and optimal timing of intervention in common congenital heartdiseases; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for congenital heart diseases.Recommendations: Evidence based recommendations are provided for indications and timing of intervention in common congenitalheart diseases, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductusarteriosus and others), obstructive lesions (pulmonary stenosis, aortic stenosis and coarctation of aorta) and cyanotic congenital heartdiseases (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebsteinanomaly and others). In addition, protocols for follow-up of post surgical patients are also described, disease wise.

Non-alcoholic chronic calcific pancreatitis in a patient of celiac disease: a rare presentation

Celiac disease is a common malabsorptive disorder in the Indian subcontinent and autoimmune dysfunction of thyroid and pancreas is frequently encountered along with. Chronic Calcific pancreatitis is a unique entity commonly seen in alcoholics but very rare in a patient of celiac disease. This case report includes the interesting constellation of calcific pancreatitis with celiac disease in a young adult male patient known case of insulin dependent diabetes and hypothyroidism. We believe it to be the only case report from north India. A 32 year old Indian male patient known case of Diabetes and hypothyroidism presented with features of malabsorption and was diagnosed with Celiac disease and calcific pancreatitis on imaging. The symptoms and insulin requirement also improved with the treatment of Celiac disease. Although a common involvement of pancreas in celiac disease, calcific pancreatitis is a rare finding and improvement of both the insulin requirement and malabsorptive symptoms with the treatment of celiac disease and pancreatitis vice-a-versa.

The role of motor nerve conduction: in cervical radiculopathy patients

Background: Cervical radiculopathy is the clinical description of when a nerve root in the cervical spine becomes inflamed or damaged, resulting in a change in neurological function. Neurological deficits, such as numbness, altered reflexes, or weakness, may radiate from the neck into the shoulder, arm, hand, or fingers. Patient also complains of tingling, numbness or loss of sensation along with the nerve root dermatome. It is a substantial cause of disability and morbidity, and its cost-effective evaluation and treatment are crucial so there is a definite need to establish a cost effective, reliable, and accurate means for establishing the diagnosis of cervical radiculopathy. Electrodiagnostic tests are the closest to fulfil these criteria out of which nerve conduction tests are one of the electrodiagnostic test.Methods: In this study motor nerve conduction of ulnar and median nerve done in 30 clinically proven cervical radiculopathy patientsResults: There are significant decrease in the conduction velocity of both nerve (median nerve (51.60±7.5), Ulnar nerve (50.60±5.6)) and significantly increased in the mean latency of both nerve (median nerve (6.02±2.4), ulnar nerve (5.8±1.8)).Conclusions: Authors concluded that MNC is the specific test for the diagnosis of cervical radiculopathy. At least the MNC of both nerves included in diagnostic criteria of cervical radiculopathy.

Hydraulic System Onboard Monitoring and Fault Diagnostic in Agricultural Machine

Abstract Agricultural Machinery as an off-road vehicle is the backbone of the World agricultural industry. Its main function is to operate as a prime mover and support the power requirements to function the various type of draft implements. In this regards, the hydraulic system is an important part and is controlled by the propagated oil which is cleaned by impurities and debris using a filter system. Once it blocks, the bypass opens to avoid any pressure burst of the system, and the particles find their way into the hydraulic system and get lodged in the gears, pumps, valves, and drive train to hinder the performance of the Agricultural Machinery. This research presents an onboard Multiple Signal Classification Algorithm (MUSIC) and pseudo-spectrum analysis as a computational tool used by cellphones to analyze the particle pollution level of the hydraulic filter. This analysis is carried out on the soundtracks recorded from different cell phones in different incremental stages of fluid contamination to the particles until it being choked, based on the standard of ISO4406.

Efficacy of Topical Diluted Autologous Serum in Patients of Dry Eye in Bundelkhand Region

Background: The dry eye is a symptom complex occurring as sequelae to deficiency or abnormalities of the tear filmwhich can lead to the persistent and progressive damage of the ocular surface. Conventional artificial tear therapies are limited in supplying the neurotrophic factors, vitamins, and immunoglobulins necessary for the health of the ocular surface. Serum has been shown to contain essential tears components in comparable concentrations to natural tears.Present study has been done to evaluate the effectiveness of diluted autologous serum eyedrops in relieving patients’ symptoms and improvement in corneal phenotype in patients of dry eye. Methods: The study included 36 eyes of 25 patients with dry eye disorder from Bundelkhand region only, who were prescribed 20% diluted autologous serum eye drops along with artificial tears. Patients were asked to apply this serum 8-10 times per day in affected eye and they were examined on end of 1st, 2nd, 4th, 6th and 8th week to determine the efficacy of the treatment. Evaluation of efficacy of autologous serum treatment for dry eye, was determined by comparing subjective and objective score calculated by a scoring system suggested by “National Eye Institute: Industry workshop on clinical trials”from day 1 to every subsequent visit for follow up. Results: We noticed that after 8 weeks’ treatment of topical diluted autologous serum, 35 cases of dry eyes showed decrease in subjective as well as objective score and only 1 case of eye did not show improvement after 8-week treatment. Conclusion: We concluded that the use of 20% diluted autologous serum tears appears to be a safe and good therapy in cases of dry eye disorder as it was effective in improvement of symptoms and objective signs even in severe dry eye disorder.

A Prospective Obsevational Study For Use Of Intranasal Dexmedetomidine In Paediatric Sedation For Diagnostic Magnetic Resonance Imaging Studies.

Context: Children undergoing MRI often require sedation to avoid motion artifacts and anxiety attacks. Dexmedetomidine is a highly selective α2 adrenoceptor agonist that has sedative and analgesic effects. Aim: This study was conducted to determine whether intranasal Dexmedetomidine 2 µg/kg offered effective sedation in children posted for diagnostic MRI studies. Methods: This prospective pilot study was conducted on 30 ASAI/II patients aged upto 12 years posted for Magnetic Resonance Imaging Studies. In this study all patients were administered with intranasal dexmedetomidine 2 µg/kg in the presence of parents, 30 minutes before scheduled MRI scan. The time of administration and reaction of children were noted. Children were observed in holding area with standard monitors applied. The degree of sedation was assessed at 15 and 30 minutes by using University of Michigan Sedation Scale (UMSS). Recovery time and recovery score were noted according to Modified Aldrete recovery score and quality of MRI is also observed. Statistical analysis:The data was entered in MS EXCELspreadsheet and analysis was represented as mean plus standard deviation. Results: Mean sedation scores after 15 minutes and after 30 minutes were 1.20±1.8 and 2.80±0.7 respectively. Mean discharge time according to modified Aldrete score was 82.42±32.68 minutes. There were no adverse events. No sneezing or coughing episodes were observed during drug administration. Conclusion: Dexmedetomidine is a useful agent for sedation of children undergoing MRI studies.

A Double Blind Randomized, Placebo Controlled Study Evaluating the Effect of Ondansetron in Reducing Spinal- Induced Hypotension Using Low Dose Bupivacaine in Parturients Undergoing Caesarean Section.

Background: Spinal induced hypotension is the most common intraoperative complication after spinal anesthesia during cesarean delivery. Various adjuvant techniques/drugs had been used in the past to minimize the haemodynamic effects of spinal anaesthesia. Five-hydroxytriptamine (5-HT), a serotonergic receptor, may be an important factor associated with inducing the Bezold Jarish reflex (BJR) that may lead to the bradycardia and hypotension in the setting of decreased blood volume. Some animal and human studies further supported that BJR can be decreased by 5-HT3 antagonists. Aim: The present study work is to assess the effects of Inj. Ondansetron (a selective 5‑HT3 receptor antagonist) in preventing spinal induced hypotension in patient undergoing elective Caesarean section. Methods: Sixty parturients scheduled for elective caesarean section were randomly allocated into two groups. Group O (30 patients): Inj. Ondansetron (4 mg IV) diluted in 10 mL of normal saline, administered 5 minutes before spinal anaesthesia and Group N (30 patients): Normal saline 10 mL given 5 minutes before spinal anaesthesia. We observed the haemodynamic parameters as our primary outcome and neonatal outcome in terms of APGAR scoring as secondary outcome. Results: Both the groups were comparable in terms of demographic characteristics. The decrease in mean arterial pressure in Group O was significantly lesser than Group N from 6 min until 30 min. The requirement of vasopressor (Inj. Phenylephrine) was significantly less in Group O than Group N (P = 0.015). Neonatal outcome in terms of APGAR Score and gas analysis were comparable between the groups. Conclusion: Inj. Ondansetron (4 mg IV), given intravenously 5 min before subarachnoid block reduced hypotension and vasopressor use in parturients undergoing elective caesarean section.

Unusual foreign body in oropharynx: a case report.

Foreign body in oropharynx is common occurrence. We report a case of a 7 month old male baby who presented with complaint of feeding difficulty and later diagnosed as case of foreign body oropharynx i.e. wheat stalk of 5 cm with overlying husk based on detailed history and meticulous examination.

Evaluation of goat based ‘Indigenous vaccine’ against Bovine Johne’s Disease in endemically infected native cattle herds.

‘Indigenous vaccine’ prepared from ‘Indian Bison Type’ a native bio-type of Mycobacterium avium subspecies paratuberculosis strain ‘S5’ of goat origin (goat based) was evaluated in indigenous cattle herds located in gaushalas (cow shelters), endemic for Bovine Johne’s disease. Cows (893) were randomly divided into vaccinated (702 = 626 adults + 76 calves) and control (191 = 173 adults + 18 calves) groups. Response to vaccination was evaluated on the basis of health (mortality, morbidity), productivity (growth rate, reproductive performance, total milk yield), immunological parameters (LTT, ELISA titer), survivability of animals naturally infected with MAP, bacterimia (by specific blood PCR), sero-conversion (by indigenous ELISA) and status of shedding of MAP in feces (by microscopy) in the two groups before and after vaccination. Reduction in MAP shedding [to the extent of 100% in Herd A; and from 82.1% (0 DPV) to 10.7% (270 DPV) in Herd C] was the major finding in vaccinated cows. Whereas, the control group cows have shown no improvement. As the first indicator of vaccine efficacy, MAP bacilli disappeared from the blood circulation as early as 15 days post vaccination, however, peak titers were achieved around 90 DPV. Peak titers initially declined slightly but were maintained later throughout the study period. Control animals did not show any pattern in antibody titers. Mortality was low in vaccinated as compared to the control groups. Vaccination of endemically infected native cattle herds with inactivated whole-cell bacterin of novel ‘Indian Bison Type’ bio-type of goat origin strain ‘S5’ effectively restored health and productivity and reduced clinical BJD. Application of goat based ‘indigenous vaccine’ for therapeutic management of BJD in native cattle herds (gaushalas) is the first of its kind.

Evaluation of ‘cattle’ and ‘Indian Bison’ type antigens of Mycobacterium avium subspecies paratuberculosis for diagnosis of Bovine Johne’s Disease using ‘indigenous ELISA’ and AGPT .

Two antigens (‘cattle’ type and ‘Indian Bison’ type) of Mycobacterium avium subspecies paratuberculosis were evaluated for diagnosis of Johne’s disease (JD) in a gaushala (cattle herd). Of the 160 cows of Sahiwal and Hariana breeds screened, 81 (50.6%) tested positive in ELISA and 66 (41.8%) in AGPT test. Using the two antigens, 33.5% tested positive in both the tests while 41.1% tested negative. Exclusively, only 8.2% tested positive in ELISA while 17.1% tested positive in AGPT. Two antigens together detected 58.9% prevalence of MAP in the gaushala. Individually, indigenous ELISA using antigen from native source of MAP proved superior to AGPT in the diagnosis of JD in cows.

Hepatoid adenocarcinoma of stomach: Case report of a rare histological variant.

Hepatoid adenocarcinoma of the stomach is a rare form of gastric carcinoma with specifi c clinicopathological features and extremely poor prognosis. Here, we report a case of a 60-year-old male patient who presented in the outpatient department with pain abdomen and constitutional symptoms. Radiological examination revealed a growth involving the antrum of the stomach while the liver and spleen were normal. The serum alpha fetoproteins were 6590 ng/ml. The patient underwent a partial gastrectomy and microscopic examination of the growth showed two types of histological patterns. Majority of the tumor displayed hepatoid differentiation with adenocarcinomatous foci. Periodic acid Schiff positive intracytoplasmic hyaline globules were seen. The tumor was immunohistochemically positive for alpha fetoprotein. The patient underwent radical gastrectomy, received chemotherapy and has been on follow-up for the past 12 months. Though known to be an aggressive neoplasm early diagnosis of hepatoid adenocarcinoma can help improve the prognosis of the disease.

Solubility enhancement of poorly water soluble drug by using nano-suspension technology.

Solubility is an essential factor for drug effectiveness, independent of the route of administration. Poorly soluble drugs are often a challenging task for formulators in the industry. Conventional approaches for enhancement of solubility have limited applicability, especially when the drugs are poorly soluble simultaneously in aqueous and in non-aqueous media. Nanosuspension technology can be used to improve the stability as well as the bioavailability of poorly soluble drugs. The problem is even more complex for drugs like itraconazole, simvastatin, and carbamazepine which are poorly soluble in both aqueous and nonaqueous media, belonging to BCS class II as classified by biopharmaceutical classification system. Formulation as nanosuspension is an attractive and promising alternative to solve these problems. Nanosuspension consists of the pure poorly water-soluble drug without any matrix material suspended in dispersion. Preparation of nanosuspension is simple and applicable to all drugs which are water insoluble. A nanosuspension not only solves the problems of poor solubility and bioavailability, but also alters the pharmacokinetics of drug and thus improves drug safety and efficacy. This review article describes the preparation methods, characterization, and applications of the nanosuspension.

In vitro evaluation of cytotoxicity of denture adhesives.

Aim: The aim of the study is to assess and compare the cytotoxicity of commercially available four denture adhesives ex-vivo. Materials and Methods: Four commercially available denture adhesives namely Metrodent powder, Fixon powder, Dentiro powder and Fixon cream were selected. Normal saline was used in control group. To evaluate the cytotoxicity of denture adhesives, macrophages were isolated from peritoneal cavity of Swiss albino mice and cell integrity/cell viability method was done by using trypan blue dye. Results: Viable cells were counted and subjected to statistical analysis. ANOVA, F and 't' test were performed, which showed statistically significant values (P < 0.001). The mean percentage of viable cells was highest in the control group (95%) and lowest in Fixon powder (55.66%), with Dentiro powder the mean percentage of viable cells was 63.66%, with Metrodent powder 67.6% while with Fixon cream it was 69.33%. Conclusion: All tested denture adhesives showed varied degree of cytotoxicity that is statistically significant. The degree of toxicity was more in Fixon powder followed by Dentiro powder and Metrodent powder with least in Fixon cream.

Prevalence, severity, and risk factors of symptomatic gastroesophageal reflux disease among employees of a large hospital in Northern India.

Background and aims Gastroesophageal reflux disease (GERD) is considered to be a common and chronic gastrointestinal disorder. The prevalence of GERD is believed to be less in Asia than in Western countries. Population-based data on GERD are lacking from India. The present study aimed at determining the prevalence of GERD symptoms in an adult Indian community and the potential risk factors associated with GERD. Methods The study population consisted of all the employees of All India Institute of Medical Sciences, New Delhi. An interview-based observational study was done on the basis of an earlier validated questionnaire. The subjects were asked about the frequency and severity of heartburn and/or regurgitation experienced by them in the previous year. These symptoms were then scored from 0 to 18. Subjects with a score of at least 4 were considered to have symptomatic GERD. Association of GERD with factors like age, sex, BMI, Kuppuswamy social class index, smoking, alcohol, NSAID use, and comorbid illness was analyzed. Results A total of 4079 employees were interviewed in person on a 29-item questionnaire from June 2003 to January 2005. Of the 4039 eligible subjects, 653 (16.2%) had GERD; 3.6% had heartburn on daily basis and 5.9% on a weekly basis. The corresponding prevalences for regurgitation were 3.3% and 5.0%, respectively. One hundred and eight of 4039 (2.7%) had severe GERD symptoms. Higher BMI (OR=1.90, 95% CI: 1.4–2.6 for BMI ≥25), current smoking (OR=1.48, 95% CI: 1.19–1.83), asthma (OR=3.13, CI: 2.06–4.76) and hypertension (OR=1.71, 95% CI: 1.16–2.50) were associated with the presence of GERD symptoms. Conclusions Prevalence of GERD in an urban adult population from northern India is 16.2% which is similar to other industrialized countries. Higher body mass index, current smoking, and presence of asthma or hypertension predisposes to GERD in our population.

Developmental profile in children with iron deficiency anemia and its changesafter therapeutic iron supplementation.

Objective. To evaluate the developmental profile of children with iron deficiency anemia (IDA) and the changes following iron supplementation. Methods. Study was conducted prospectively in a tertiary care teaching institution. Subjects were children aged 6 months to 5-years, with IDA, proven by hematological parameters and iron studies. Complete blood counts and iron studies were performed at the beginning and following 3-months therapy with iron. Simultaneously, development was assessed by Developmental profile II (DPII), which was interpreted using IQ equivalent (IQE) scores and ‘fractional months differential’ (FMD). Results. Thirty five children fulfilled predetermined inclusion criteria. The mean-age was 22.3±13.4 months. Majority (71.4%) had moderate, while 5 (14.3%), each had mild and severe anemia. Significant developmental delay was observed in iron deficient children. Maximum delay was observed in academic and communication domains. 6 (17.2%) failed developmental screening, with IQE scores of <70. Significant improvement in DPII scores was noticed following therapy. Although some gain in IQE scores was noticed in the majority (88.6%), significant improvement (e =>10-point gain) was observed in about half (51.4%). Interpretation of DPII by FMD revealed significant improvement in all the domains as well. Conclusion. Children with IDA have suboptimal developmental scores. The delayed development is variably reversible following oral iron therapy. Hb =<7 g/dl and age >24 months predict suboptimal outcome. FMD is a useful method of interpreting DPII.

Early intervention in developmental delay.

A 10-month-old child with prenatal history of vaginal bleeding in mother at 8 weeks of pregnancy, delivered by cesarean section and history of neonatal jaundice was bought with poor social smile, poor eye contact, and inability to sit independently. He was enrolled in early intervention programme, which included relaxation exercises, passive exercises, visual stimulation and auditory stimulation. By the end of 8 months of the therapy, he could walk independently, was able to pick glassful of water and keeping away after drinking, was using disyllabic words meaningfully, could indicate for hunger and toilet and was able to recognize the parents and self.

Can clinical symptoms or signs accurately predict hypoxemia in children with acute lower respiratory tract infections?

OBJECTIVES: To determine clinical predictors of hypoxemia in children with acute lower respiratory tract infection (ALRI). DESIGN: Cross-sectional study. SETTING: Emergency department of All India Institute of Medical Sciences, a tertiary care hospital. SUBJECTS: 109 under five children, with ALRI. METHODS: Clinical symptoms and signs were recorded. Oxygen saturation was determined by a pulse oximeter. Hypoxemia was defined as oxygen saturation less than 90%. The ability of various clinical symptoms and signs to predict the presence of hypoxemia was evaluated. RESULTS: Twenty-eight (25.7%) children were hypoxemic. No symptoms were statistically associated with hypoxemia. Tachypnea, suprasternal indrawing, intercostal indrawing, lower chest indrawing, cyanosis, crepitations, and rhonchi were statistically significantly associated with hypoxemia. A simple model using the presence of rapid breathing (> or =80/min in children < or =3 m, > or =70/min in >3-12 m and > or =60/min in >12 m) or lower chest indrawing had a sensitivity of 78.5% and specificity of 66.7% for detecting hypoxemia. No individual clinical symptom/sign or a combination had both sufficient sensitivity and specificity to identify hypoxemia. CONCLUSION: None of the clinical features either alone or in combination have desirable sensitivity and specificity to predict hypoxemia in children with acute lower respiratory tract infection.